On the pulse

At the RCN Congress in Liverpool this week, some of the most pressing issues facing the nursing profession were on the agenda. In particular, two stories covered by Nursing Times highlighted the need for greater awareness of the value of some nursing roles.

Patient advocacy: breaking down barriers and challenging decisions

Nurses sometimes find it daunting to speak up on behalf of patients, because it involves challenging other people’s decisions, behaviours or beliefs. This article comes with a handout for a journal club discussion

Abstract

Why do nurses sometimes fail to speak up for a patient whose best interest is at risk or whose wellbeing is compromised? This article discusses the role of nurses as patient advocates and the reasons why some find it difficult to fulfil their responsibilities in this area. Via a selection of narratives from real-life situations, the article raises questions and prompts readers to reflect on their ability to challenge other people’s decisions, behaviours or beliefs. This is the first in a series of occasional articles using narratives to investigate issues in nursing.

Introduction

Why do nurses sometimes fail to advocate on behalf of patients whose best interests are being compromised? The Nursing and Midwifery Code states it is the responsibility of nurses to “act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care” (Nursing and Midwifery Council, 2015). However, nurses sometimes struggle to assume this responsibility. What is it that prevents them challenging other people’s decisions, inappropriate behaviours or misplaced beliefs, in or outside the workplace?

This article explores the difficulties nurses face in their role as patient advocates and prompts readers to reflect on their own practice, via real-life narratives and reflection points relating to each. It is the first in a series of occasional articles using narratives to investigate issues in nursing, which follows on from a previous series that explored the use of narratives as a means of reflecting on practice (Box 1).

Box 1. Using narratives to reflect on practice

A series of seven articles published in Nursing Timesin March and April 2016 explored the use of narratives for reflecting on practice. It highlighted how patients’ stories about their experiences of care offer invaluable opportunities for nurses to understand how their practice is perceived.

The first narrative is set in an emergency department (ED) and involves a young woman who had a serious facial wound.

The nurse felt the decision made by the junior doctor in charge of the patient’s care was not the right one. She tried to argue her case but gave up, failing to assert her professional judgement, which resulted in negative consequences for the patient. Many years after the incident, she is still unhappy about her behaviour.

Case 1: challenging a colleague’s knowledge

Helen Taylor, in her early 20s, attended the ED with a wound approximately 10cm long across her left cheek after having been attacked with a knife. The nurse took a handover from the ambulance crew, assessed Ms Taylor and temporarily covered the wound.

Then, a junior doctor who was two months into his first ED rotation saw Ms Taylor. The nurse suggested that he refer Ms Taylor to the nearest plastic surgery unit for review by a plastic surgeon, as previous experience told her this was the best course of action with this type of wound. The doctor replied that he was more than capable of suturing the wound – his ultimate career goal was to become a plastic surgeon. The nurse pointed out that neither his ability nor his career path were in question, but that it was in Ms Taylor’s best interest to be seen by a plastic surgeon. The doctor went ahead regardless and sutured Ms Taylor’s face.

Despite being more experienced, the nurse felt she had to give in and did not confront the doctor further. She has seen Ms Taylor several times since, and each time she is reminded of the events of that night. Extensive scarring is now the most notable feature of Ms Taylor’s face. The nurse regrets not having asked the on-call consultant to intervene. She believes that, if she had stood her ground, Ms Taylor would now have a less prominent and image-damaging scar.

Confidence issue

Nurses often find themselves in situations that are similar to the one described above, in which patients depend on them to speak up on their behalf. These types of incidents still occur in many healthcare settings where nurses find it difficult to challenge the decisions made by other people (Churchman and Doherty, 2010). Churchman and Doherty (2010) suggest that personality, age, gender, fear, lack of confidence and occupational hierarchy could all be implicated.

In Ms Taylor’s case, the nurse’s surrender and inaction stemmed from her fear of confrontation and lack of confidence, while the junior doctor was, on the contrary, full of confidence. Also, in that ED’s culture, nurses were not expected to question doctors: there was a distinct occupational hierarchy, with nurses being seen as subordinate to doctors. Such a hierarchical structure creates an obstruction, making it difficult for nurses to raise concerns they may have about medical decisions (Department of Health, 2001). This type of culture has been reported to be potentially detrimental to patient care (Francis, 2013; DH, 2001).

Box 2 features reflection points on Ms Taylor’s case that you can use to think about your own practice.

Box 2. Reflecting on Case 1

Think of a time when you failed to speak up to defend a patient’s best interest:

What could you do to address the reason that prevented you from advocating on behalf of that patient?

Case 2: protecting people who are vulnerable

A learning disability nurse was walking through his local town centre when he saw Philip Smith, a man he knew who had a learning disability, being pointed and laughed at by four teenagers. Mr Smith looked upset. The nurse walked past the group of teenagers, casting them what he hoped was a disapproving glance, but said nothing to them and continued on his way.

The NMC Code states that nurses must “take all reasonable steps to protect people who are vulnerable or at risk from harm, neglect or abuse” (NMC, 2015). Box 3 features reflection points on Mr Smith’s case.

Box 3. Reflecting on Case 2

What do you think might have inhibited this nurse from speaking up on behalf of Mr Smith?

Do you think a nurse should say something in such a situation?

What do you think you might have done in a similar circumstance?

What would you consider “reasonable steps”, as described in the NMC Code, in this instance?

Case 3: challenging qualified colleagues as a student

Linda Baker, a girl in her late teens who was dangerously underweight, was admitted to a specialist eating disorder unit. The team on that unit had been together for a number of years, and considered an older member of staff as the most experienced and knowledgeable. A student nurse heard this senior care worker shout at Ms Baker: “You know what you are doing? Just eat your food and stop making such a fuss. You are just attention seeking.” Although Ms Baker’s care plan explicitly stated that no reference to food should be made to her and that staff should avoid confronting her, the student nurse looked away and busied herself with another patient.

The NMC states that as a nurse you must “raise and, if necessary, escalate any concerns you may have about patient or public safety, or the level of care people are receiving in your workplace or any other healthcare setting, and use the channels available to you in line with our guidance and your local working practices” (NMC, 2015). Box 4 features reflection points on Ms Baker’s case.

Box 4. Reflecting on Case 3

Think of a time when you did not comment on a colleague’s inappropriate attitude towardsa patient:

Why did you fail to speak up?

What might have been the consequences of you speaking up for everyone involved (patient, staff member, yourself)?

What courses of action did you feel were available to you?

Case 4: challenging family members

Three-year-old Jack Parker attended the ED with a 5cm deep wound on his forehead, which he had sustained from a fall while out on a country walk with his parents. He had fallen down a steep hill and hit his head several times before landing in a puddle. His wound was cleaned and adhesive dressings were used to close it. There was a high risk of tetanus, so Jack also needed a tetanus injection booster. Jack’s parents were asked whether his immunisations were up to date, to which they replied that he had never been immunised because they believed vaccinations were toxic and would cause him more harm than good. They did not think Jack was at risk, because he was healthy, besides which they had never heard of a case of tetanus in this country.

The nurse gave Jack’s parents extensive information about tetanus and how it can be prevented by an injection, pointing out that tetanus was a rare occurrence precisely because of immunisation. However, they made it clear that they would not give their consent for an injection. They left with advice on how to care for the wound and what signs and symptoms should ring an alarm bell, and were told to come back immediately if they had any concerns.

The nurse was left feeling that perhaps there was something more she could have done to persuade Jack’s parents to let him have the injection.

The NMC states that nurses must “make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay”, but also that they must “respect and uphold people’s human rights”. Box 5 features reflection points on Jack’s case.

Box 5. Reflecting on Case 4

Would you have done anything differently to this nurse?

Do you think nurses have a right to challenge carers’ and/or parents’ beliefs?

Think of a time when your opinion on a patient’s best interest differed from that of the patient’s relative or carer, but you did not contend with them enough to persuade them to change their mind:

Do you think you achieved the right balance?

What might have inhibited you from advocating more assertively?

Case 5: challenging a colleague’s decision

A nurse in charge of an orthopaedic ward on night duty asked the on-call anaesthetist to assess a patient who was in severe pain after back surgery. Max Foster, 52 years old, had been prescribed morphine as required, but this was not enough to control his pain. The nurse asked the anaesthetist to allow medication to be administered via a patient-controlled analgesia pump. The anaesthetist refused on the grounds that Max Foster “had had enough morphine”. The nurse reiterated that, despite the as-required morphine, the patient was still in severe pain. She made it clear that if Mr Foster was not given adequate pain relief, she would take the incident further. The anaesthetist reluctantly came on the ward and prescribed adequate medication, which reduced Mr Foster’s pain to an acceptable level.

In this case, the nurse did act along the lines of the NMC Code, being assertive and persistent in her efforts to advocate on Mr Foster’s behalf. She was able to “act as an advocate for the vulnerable, challenging poor practice” and ensured the “fundamentals of care” were delivered effectively (NMC, 2015), thereby ensuring that the patient received appropriate treatment in a timely manner. Box 6 features reflection points on Mr Foster’s story.

Box 6. Reflecting on Case 5

Think of a time when you believe you did speak up in a patient’s best interest, despite there being a perceived conflict with a colleague:

What were the consequences for the patient?

How did you feel afterwards?

What do you think allowed you to be so assertive and persistent?

Occupational hierarchies

Some of the stories shared in this article should make you consider whether the traditional perception of the doctor-nurse relationship (doctors deemed superior to nurses, nurses considered doctors’ ‘handmaids’) still permeates the culture in certain healthcare settings. In recent years, there have been many documented cases in which the safety of patients was put at risk in settings perceived as being highly hierarchical, the concluding evidence being in favour of a ‘flattening’ of these hierarchies (Reid and Bromiley, 2012). These perceived hierarchies are certainly one of the reasons why nurses hesitate to speak up and advocate for their patients.

Conclusion

Nurses often find themselves in the position of supporting vulnerable people who are not able to speak up for themselves because of factors such as illness, mental capacity or social position. The NMC requires that, when patients’ wellbeing is threatened, nurses advocate on their behalf. However, for reasons such as age, gender, attitude to power, personality, social situation or conflict regarding professional roles, nurses may be reluctant to raise their heads above the parapet. Nurses should try to find ways to overcome the barriers hindering them to play their role in patient advocacy.

All patient names in this article have been changed to protect the identity of the individuals concerned.

Key points

The Nursing and Midwifery Code states that it is the responsibility of nurses to “act as an advocate for the vulnerable”

Nurses can find it difficult to challenge decisions made by others

Factors hindering nurses in their advocacy role include age, gender, attitude to power, personality, role conflict or social situation

Strict hierarchies make it more difficult for nurses to raise concerns about patient care

Nurses must find the resources to speak up if needed so that patients receive adequate and timely care

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